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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940 |
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | |||
Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB control number. | SEC 1474 (9-02) |
1. Title of Derivative Security (Instr. 3) |
2. Conversion or Exercise Price of Derivative Security | 3. Transaction Date (Month/Day/Year) | 3A. Deemed Execution Date, if any (Month/Day/Year) | 4. Transaction Code (Instr. 8) |
5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4, and 5) |
6. Date Exercisable and Expiration Date (Month/Day/Year) |
7. Title and Amount of Underlying Securities (Instr. 3 and 4) |
8. Price of Derivative Security (Instr. 5) |
9. Number of Derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) |
10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) |
11. Nature of Indirect Beneficial Ownership (Instr. 4) |
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Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Weiss Dana A C/O MARK D. BALK, GOULSTON & STORRS, PC 400 ATLANTIC AVENUE BOSTON, MA 02110 |
Member of Schedule 13D group |
/s/ Mark D. Balk, Attorney-in-Fact | 12/02/2004 | |
**Signature of Reporting Person | Date |
* | If the form is filed by more than one reporting person, see Instruction 4(b)(v). |
** | Intentional misstatements or omissions of facts constitute Federal Criminal Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). |
(1) | Represents (1) a gift of 350 to Robert A. Smith and Dana Weiss 1994 Childrens Trust udt dated December 1, 1994 fbo Jackson A. Smith, of which the reporting person and Mark D. Balk are trustees; (2) a gift of 350 to Robert A. Smith and Dana Weiss 1994 Childrens Trust udt dated December 1, 1994 fbo Ryan A. Smith, of which the reporting person and Mark D. Balk are trustees; and (3) a gift of 350 to Robert A. Smith and Dana Weiss 1994 Childrens Trust udt dated December 1, 1994 fbo Madeleine W. Smith, of which the reporting person and Mark D. Balk are trustees. |
(2) | Reflects the shares held directly and indirectly by the following persons or entities and indirectly by Dana A Weiss 175,463 shares owned directly by Robert A Smith, husband of the reporting person: 39,091 shares owned indirectly by Robert A Smith as a trustee of the Susan F Smith Grantor Retained Annuity Trust 5 Years udt dated September 1, 1998 fbo Robert A Smith, 28,997 shares owned indirectly by Robert A Smith as a trustee of the Susan F Smith Grantor Retained Annuity Trust - 7 Years udt dated August 10, 1994 fbo Robert A Smith, |
(3) | 4,741 shares owned indirectly as a trustee of the Robert A Smith and Dana Weiss 1994 Childrens Trust udt dated December 1, 1994 fbo Madeleine W Smith, 4,741 shares owned indirectly as a trustee of the Robert A Smith and Dana Weiss 1994 Childrens Trust udt dated December 1, 1994 fbo Ryan A. Smith, 4,741 shares owned indirectly as a trustee of the Robert A Smith and Dana Weiss 1994 Childrens Trust udt dated December 1, 1994 fbo Jackson A Smith, 52,360 shares owned indirectly by Robert A Smith and the reporting person as trustees of the Robert A Smith Grantor Retained Annuity Trust, 16,069 shares owned indirectly as a trustee of the Robert A Smith 1998 Grantor Retained Annuity Trust fbo Jackson A Smith, 16,070 shares owned indirectly as a trustee of the Robert A Smith 1998 Grantor Retained Annuity Trust fbo Madeleine W Smith, 16,069 shares owned indirectly as a trustee of the Robert A Smith 1998 Grantor Retained Annuity Trust fbo Ryan A Smith, |
(4) | 48,208 shares owned indirectly by Robert A Smith as a trustee for the Robert A Smith 1978 Insurance Trust, 6,686 shares owned indirectly by Richard A Smith and the reporting person as guardians of the property of Madeleine W Smith, 6,686 shares owned indirectly by Richard A Smith and the reporting person as guardians of the property of Ryan A Smith, and 6,686 shares owned indirectly by Richard A Smith and the reporting person as guardians of the property of Jackson A Smith. The reporting person disclaims beneficial ownership of all of these shares, and this report shall not be deemed an admission that the reporting person is the beneficial owner of such securities for purposes of Section 16 or for any other purpose. |